November 1, 2005 | Healthcare Risk, Quality, & Safety Guidance
Since the 1999 release of the Institute of Medicine report To Err Is Human: Building a Safer Health System, patient safety has been a major focus of government agencies, consumer groups, and professional associations. For example, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) includes patient safety standards for accredited hospitals; the Centers for Medicare & Medicaid Services uses increased reimbursement as an incentive for quality data reporting hospitals to receive; and a number of states have implemented medical-error reporting systems.
Many safety experts note that initiatives to improve patient safety in healthcare organizations should be preceded by changes in the culture of safety in order to be successful. Most general descriptions define safety culture as the collective product of individual and group values and attitudes, competencies, and patterns of behaviors in safety performance. It is, in either a positive or negative sense, "the way we do things around here." A culture of safety, in which everyone accepts responsibility for patient safety, is necessary before other patient safety practices are introduced. Otherwise, individuals expected to implement the safety initiatives are unable to effectively communicate or work together. After all, good teamwork and communication are...